Increasing Men’s Involvement in Family Planning

The authority in global health governance, WHO, asserts that “family planning^[1] allows people to attain their desired number of children and determine the spacing of pregnancies. It is achieved through the use of contraceptive methods and the treatment of infertility” (2017). However, there are 214 million women in developing countries who do not use any modern contraceptive method although they desire to avoid pregnancy (WHO 2017). The benefits of family planning are numerous and range from reducing adolescent pregnancy to decreasing pregnancy-related risks (See https://www.guttmacher.org/report/contraception-and-beyond-health-benefits-services-provided-family-planning-centers). Nevertheless, there are still many countries with low rates of contraceptive use. Guyana, being one of them has a contraceptive prevalence rate of only 34% (UNICEF 2016). This low rate reflects the country’s inability to cater to its nation’s reproductive health; according to WHO, the contraceptive prevalence rate “serves as a proxy measure of access to reproductive health services” (2006). Moreover, the United Nation Population Fund (UNFPA) State of the World Population reveals that Guyana has the second highest rate of adolescent pregnancy in South America and the Caribbean (2013).

[1] Family planning – In this paper family planning refers to the use of contraception and the two terms will be used interchangeably to refer to methods to prevent pregnancy.

It is against this backdrop that this paper aims to focus on the development of a pilot health intervention to increase men’s involvement in family planning (FP) in a rural village in Guyana. It will explore the theoretical perspectives of radical feminism and hegemonic masculinity in relation to contraception. Subsequently, it will examine how hegemonic masculinity will shape the intervention along with how the gender analysis matrix (GAM) will be employed. Lastly, a synopsis of the proposed intervention will be presented.

Theoretical Perspectives/Background

Contraception is paramount to the realization of the aims of feminism (Espey 2015) and its usage has been ‘feminized’ (Hebert 2014). Socialist feminism contends that women deserve unlimited access to contraception (IPPF 2015). While, radical feminism argues that “women’s subordination is rooted in male control over women’s fertility and sexuality, that is, over women’s bodies.” (Connelly et al. 2000, p.124). Satz further supports radical feminism stance by asserting that men have historically had power over women’s bodies by ‘managing’ their sexuality and reproduction (2004). Hence, men may prohibit the use of contraception as a means of maintaining that power. However, radical feminism does not explain why some men allow their partners to use contraception but they themselves are not actively engaged in contraception usage. Therefore, hegemonic masculinity will be utilized to provide reasons for this.

The creation of the birth control pill was a significant landmark in the women’s rights movement (Campo-Engelstein 2012). Gretchen asserts that the history of the pill and the history of feminism are intricately linked, since if women can control their reproduction they also have control over their lives and the first-wave feminists knew this. She further elaborates that it was Margaret Sanger, the founder of the International Planned Parenthood Federation (IPPF) who coined the term “birth control” and the release of the pill in 1960 heralded in the second wave of feminism. Further, it is the belief of many that unlimited access to every kind of contraception is the only way to be a feminist and to oppose contraception is to be anti-women (2016).

Although contraception is widely praised, its use is still contested in the world of feminism. According to Purdy 1996 “Progressive left” feminists, thought that contraception reinforced ‘biologically deterministic stereotypes’ of women. While some feminists insisted that contraception made reproductive matters solely the responsibility of women (Sawicki 1999). This is a valid argument since the campaigns to increase contraceptive uptake often targets females only in Guyana and the world over. Further, in a postfeminist society that claims to have ‘achieved’ sexual liberation, contraception is being used to stop women’s menstruation (Harris et.al 2014). In addition, Freeman declares that in the late 1800s many feminists were against condoms since it was tied to married men’s promiscuity. While, later feminists such as Margaret Sanger, rejected the use of the male condom because they felt with this method of birth control men were wholly in control of contraception. However, in the 1970s, some feminists viewed the pill as a representation of patriarchy in the predominantly male medical and pharmaceutical field and the dangers associated with the usage of the pill were withheld from women which infringed on their rights to informed consent (2018).

While hegemonic masculinity will be used to give understanding to why men are not involved in the FP process in the rural village of Guyana. Hegemonic masculinity is a range of patriarchal practices that enables the sustenance of dominion over women and other types of masculinities (Connell and Messerschmidt 2005). In the Caribbean, for most men, the validity of their manhood depends on a “normative, straightjacket or dominant masculinity” and showing no features of tenderness or ‘femininity’ (Davis and James 2014). However, affirming to such limiting determinations of manhood leads “to disengaged fatherhood, poor health, aggression, overwork, and lack of emotional responsiveness” (Ruxton 2004, p. 10).

It is this type of masculinity that tells men that they should operate in a certain manner and that matters of reproductive health is a ‘woman’s business’. Men’s perspicacity of reproductive health is a matter for females along with the thinking that use of contraceptives will result in women being unfaithful acted as barriers in Uganda to contraceptive use (Atuyambe et al. 2014). Interestingly, in Nepal, the belief that contraception encourages women to be promiscuous resulted in men willingly using male methods of contraception to prevent their partners from using contraception (MOPH Nepal et .al 2012, cited in FHI 360 2012, p.2). Further, studies also show that males believe that protection against pregnancy is the sole responsibility of the woman (Greene et.al 2011). Opposition to the use of condoms is also a deterrent to involving men in FP (FHI 360 2012). For example, males in Bangladesh oppose condoms since they believe that condoms lessen sexual pleasure (Shahjahan and Kabir 2007).

Mula proclaims that women’s reproductive freedom and hegemonic masculinity cannot co-exist and the rights to abortion and contraception threaten this form of masculinity through:

“(1) freeing resources to compete with men for social, legal, and economic power that women might otherwise expend bearing and rear unwanted children; (2) destabilizing production relations by granting women greater ability plan to take on traditionally male-dominated jobs; and (3) destabilizing relations of cathexis by permitting women to explore their sexuality”. (Mula nd)

Essentially, hegemonic masculinity negatively affects the use of FP because it pressures males to openly denigrate the use of contraception based on masculine ideals (Graffty nd).

However, the saying ‘men are not concern about pregnancy prevention’ has been contested. Perveen insists that antithetical to that general belief, men have an interest in FP but in developing countries, they have been excluded from FP programs, other than those of vasectomy or condom distribution (2011). Further, Darrach asserts that some men are willing to accept responsibility for contraception even though pregnancy prevention programs over the last forty years has been virtually centered on women.  He also states that male FP methods presently account for 38% of all reversible contraceptive usage, and 28% of women of childbearing age rely on their partner’s vasectomy as their form of birth control (2000). In a credible study by Ojofeitimi et al confirmed that most men believed that decisions in relation to FP should be made by both spouses rather than by one party contradicts the frequently held notion that men are against FP and governs contraceptive decision-making (2007).

However, the theory of hegemonic masculinity is not without its flaws and there have been several critiques of it (Connell and Messerschmidt 2005). One such critique is that it is based on heteronormativity (Whitehead 2002). Further, it often depicts men as either yielding to dominant gender norms or being excluded by them (Connell and Messerschmidt 2005). While Anderson found that hegemonic masculinity could not justify the social dynamics of the male peer groups that included gay men. He then examined the association between homophobia and the construction of masculinities (Anderson and Mc Cormack 2016) and proposed the inclusive masculinity theory where masculinities exist in a less arranged order of rank and devoid of homohysteria (Anderson and McGuire, 2010).

Moreover, there are many other factors which intersect that leads to the contraception ‘burden’ being placed on women and cannot be fully explained by either masculinities and/or feminist theories. Even, the general ideas of masculinity are peculiar to sociocultural settings and determined by many agents such as sexual orientation, culture, class, and ethnicity (Connell 1995; Kimmel 2000). Therefore, the Intersectionality theory that was created by Crenshaw, which has its origin in black feminism is an appropriate viewpoint which can examine the numerous factors which lends to contraception being gendered. Moreover, Intersectionality transcends the well-known causes of inequality (Crenshaw 1989; Hankivsky 2012) and ‘digs’ deeper for the reasons the weight of pregnancy prevention is placed on the female.

However, hegemonic masculinity was seen to be more fitting to explore the lack of male involvement in FP in Guyana and to subsequently develop an intervention to combat it. Moreover, Blackbeard et. all declares that the theoretical concept of hegemonic masculinity needs to be included in gender interventions and this inclusion can give rise to changes in men’s attitudes, their view of what it means to be a man and their relations with women (2005). Hence, it was chosen as the theory to shape the intervention.

The Planning Framework

The GAM was created by Rani Parker along with development practitioners from a Middle Eastern Non-Governmental Organization in response to an expressed need for an appropriate framework for their grassroots work (March et 2000). It provides a community-based approach to the examination of gender differences which aids in the identification of the potential impacts of the intervention on women and men and it also challenges the community’s preconceptions about gender roles (March et. al 200). However, unlike the Harvard method, which is used by professional planners, it was created to be used in the field (World Bank nd). It carries out analysis at four levels: women, men, household and the community and examines the impact on labor, time, resources and culture (March et al 2000).

Why GAM Was chosen?

The theoretical perspective of hegemonic masculinity underpins the intervention. Hence, a tool that included men was necessary and the GAM was ideal because it is a framework that includes men and could be used in interventions that target them (March et al 200). Further, to ensure the desired synthesis existed between the theoretical perspective informing the intervention and the tool that will use to ensure gender sensitivity the GAM was chosen. moreover, the GAM was selected because it uses ‘bottom-up analysis’ and as a tool it can be used to predict the likely impacts of a given intervention and since it involves analysis of gender issues, it can lead to awareness raising of gender issues within the community which can result in other forms of development (World bank nd).

However, the GAM is not without its shortcomings: It gives almost no detailed data for later analysis; hence a series of meetings are required (World Bank nd). Further, a good facilitator is needed. Also, it can be difficult to define who is a part of the community, vulnerable members may be excluded, it does not perform macro and institutional analysis, and it does not make clear which women and which men are likely to benefit from the impacts of the project (March et.al 2000). However, as Kabeer (1995) rightly declares: “No set of methods are in themselves sensitive to differences and inequalities between men and women; each method is only as good as its practitioner” (cited in March et.al 2000, p.14).

How will GAM be employed in the Intervention?

The GAM is meant to be accompanied by other conventional tools of analysis (March et.al 2000). Therefore, the community leaders will be contacted, and a community needs assessment will be done. Before the commencement of the project, a session will be held with both male and female community members in equal propositions where the GAM matrix will be filled (See https://www.gdrc.org/gender/gender-ests.html). Subsequently, the group will discuss the following questions: “1) Are the effects listed on the GAM desirable? Are they consistent with the programme’s goals? 2) How is the intervention affecting those who do not participate?” (March et. al 2000, p.70)

First, the GAM will be used at the planning stage to ascertain if the possible gender effects are acceptable and in harmony with the goals of the intervention (Parker 1993, cited in March et.al 2000, p.69 ). Further, it will be utilized throughout the intervention since it can be used; “at the design stages where gender considerations may change the design of the project; or during monitoring and evaluation stages, to address broader programme impacts the analysis” (Parker 1993, cited in March et.al 2000, p.69). The GAM will be filled initially once a month for three months, and then once every three months consequently (March et 2000). As a result, the intervention will not be static but one which will change to accommodate the findings from the matrix.

To avoid the ‘project trap’ as described by Kabeer (1994.cited in March et.al 2000, p.14), the practitioner is conscious that “gender equality must be fought for at other levels and by other means” (March et.al 2000, p. 14) other than by using gender analysis tools. In addition, the practitioner will continually bear in mind that while the GAM presents a satisfactory means for data collection, it does not supply the answers (Warren 2007).  Caution will also be taken to ensure that it is not only gender roles that are being examined but also gender relations since Kabeer warns that analyzing gender-roles does not undeviatingly explore how power is distributed (1992) in a community. Moreover, while using the GAM the practitioner will be conscious that frameworks are not fully generalizable (March et. al 2000) and in different cultures can post issues due to them arising from another setting, possibly conflicting with local beliefs (Mukhopadhyay and Appel 1998; Wendoh and Wallace 2006).

The Intervention

This intervention is a pilot project that aims to increase men’s participation in the FP process in Guyana, South America. The focus is on men since it has been noted that the sole responsibility of preventing pregnancy is left on the women. However, it is the man who has the decision-making power and the one who decides if she will be allowed to use contraception. This finding in the country is supported by research that has shown that the male partner has the most important influence on a woman’s decisions about childbearing and contraception, yet FP programs have been solely women focused (Harper and Jezowski 1991). Studies have also depicted that providing men with information can help them to be more supportive of contraceptive use (Adelekan et.al 2014) and in its continued and effective use (Engender health and UNFPA 2017). Michael Kaufman (2003) contends that developmental work has neglected to concentrate on males which have resulted in continued male dominance in gender relations and the marginalization of women and their struggles (Cited in Ruxton 2004, p.11). Moreover, as a family planning advocate, I have realized that it is counterproductive not to include men in FP programs (https://www.globalhealthnow.org/2017-08/shattering-taboos-guyana-qa-patricee-douglas).

To move forward men must be engaged whether feminists agree or not since the reality is that men are the ones who hold the decision-making power both in the private and public sphere (Perveen 2011). Moreover, there have been international commitments to encourage male involvement such as “the landmark International Conference on Population and Development’s (ICPD) Goals and Targets 1994, that called for an understanding of men’s and women’s joint responsibilities, so that they could become equal partners in public and private life, and to encourage and enable men to take responsibility for their sexual and reproductive behaviour” (Perveen  2011).

The intervention will engage men in FP through community outreach and service provision (See https://www.fhi360.org/sites/default/files/media/documents/MaleEngageBrief.pdf) in the form of a male SRH clinic. It borrows best practices from a similar project that was done in Bangladesh (See https://www.fhi360.org/sites/default/files/media/documents/MaleEngageBrief.pdf ). However, it will be adapted to the local context. Moreover, the intervention will be gender transformative with the aim to change men’s perception of FP since “the research work shows that male motivation projects should…convince men that family planning is not only for women but men as well” (Soremekun 2014, p.1).

The SRH clinic in the village that claims to be gender neutral but only caters to the needs of females will implement a once per week clinic that caters to the SRH need of men with a special focus on family planning. These sessions will be facilitated by local male nurses and community health workers. The facilitators will be trained in gender and how to involve men in conversations about their SRH. The constructive male engagement framework, which is used to engage men in reproductive health as clients; supportive partners; and change agents (PRB 2018) will be employed in this intervention.

The expected outcomes of the health intervention are that the local men will become:

• Contraceptive users or partners using methods requiring active cooperation.
• Engaged in open communication and decision-making about FP and contraceptives.
• Advocates for gender equality and FP in the community.

The intervention will be evaluated using specific indicators developed for the monitoring and evaluation of programs to increase men’s engagement in FP (See https://www.measureevaluation.org/resources/publications/tr-17-203).

Challenges

As with all projects, there will be challenges and with one of this nature that seeks to challenge the dominant form of masculinities, a few are expected. The writer will present possible challenges that may arise from the literature and what has arisen from work that she has done in the field as it relates to involving men in family planning. Firstly, it is going to be difficult at the beginning of the intervention to get men to access the services since “many men are resistant to changing ideas, beliefs, and behaviors” (Ruxton 2004, p.4). Therefore, it will be essential to have community champions – men from the community that other men respect promoting the cause. Further, clinics operate in Guyana are from 8:00am-4: 00pm and those are the hours men are at work. Moreover, while men’s engagement programs are essential, it is imperative that they are undertaken cautiously as not to serve as a tool to lead to an increase in men’s decision-making power and a decline in women’s bodily autonomy (FHI 360 2012). Therefore, this intervention presents a potential risk of the local men deciding on a contraception method for their partners without it being a shared decision. Hence, it is imperative that gender norms are addressed during the intervention (Engender health and UNFPA 2017).

Written by: Dr. Patricee Douglas MBBS, Msc.

Edited by: Dr. Terrence Isaacs MBBS.

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